Int J Child Adolesc Health 2012;5(4):403-419

ISSN: 1939-5930
Nova Science Publishers, Inc.

Adolescence and contraception

Donald E Greydanus, MD,
Carolyn M Lentzsch-Parcells, MD,
Hatim A Omar, MD,
and Colleen B Dodich, MD
Department of Pediatric and Adolescent Medicine,
Western Michigan University School of Medicine,
Kalamazoo, Michigan and Adolescent Medicine and
Young Parent Programs, J422 Kentucky Clinic,
Department of Pediatrics, Kentucky Childrens Hospital,
University of Kentucky College of Medicine,
Lexington, Kentucky, United States of America

Abstract
The age of adolescence is the time when most adolescents
in the world become sexually active with resultant millions
of pregnancies and sexually transmitted diseases. This
paper considers methods of contraception for these
adolescents, including oral contraceptives, transdermal
contraception, mini-pills, intravaginal ring, injectable
contraception, intrauterine devices, barrier contraceptives,
implants, and others. It is important for clinicians caring for
sexually active youth to provide information regarding
contraception and appropriate contraceptive prescriptions.
Keywords: Adolescence, contraception

Introduction

Correspondence: Professor Donald E Greydanus, MD,

Department of Pediatric and Adolescent Medicine,
Pediatrics Program Director and Founding Chair, Western
Michigan University School of Medicine, 1000 Oakland
Drive, Kalamazoo, MI 49008-1284 United States. E-mail:
donald.greydanus@med.wmich.edu

The median age of first intercourse in the United

States, Western Europe, Eastern Europe (Ukraine),
Eurasia (Russia), and other parts of the world is 16
years of age, with many youth having multiple sexual
partners. Clinicians caring for adolescents should ask
about possible coital behavior and provide effective
contraception to those youth continuing to be sexually
active without intent of becoming pregnant (1-23).
Table 1 lists questions helpful to ask when discussing
contraception with adolescentsparticularly if they
are sexually active.
A number of effective and safe contraceptive
methods (see Table 2) are available for the sexually
active adolescent who wishes to avoid pregnancy. The
most effective methods of contraception include
abstinence, combined oral contraceptives (24),
transdermal contraceptive patch (Ortho Evra),
vaginal contraceptive ring (NuvaRing), progestinreleasing implant (Implanon), IUDs, and
intramuscular medroxy-progesterone acetate (DepoProvera, DMPA); these methods have pregnancy rates
under 1/100 woman years of use (see Table 3).

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Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

Table 1. Questions for Adolescents Seeking Contraception

1.
2.
3.
4.
5.
6.
7.
8.

What methods have you used before, if any?

Did you have any problems with your previous method? What did you like/dislike?
Do you have any concerns about the different methods of contraception?
If your friends use contraception, what comments have they made?
Will you be able to use these methods correctly? Which ones?
Is your weight of concern to you? Have you been or are you now dieting?
Some methods may lead to unplanned, irregular bleeding. Can you deal with that?
Have you heard about any problems with the pill or other methods, such as possible weight gain or
infertility?
9. Are you aware of minor side effects that the pill may cause?
10. Do you have questions I have not answered?
Table 2. Contraceptive Methods

Abstinence
Rhythm method of contraception (periodic abstinence)
Calendar
Ovulation method
Symptothermal
Postovulation
Oral Contraceptives (Combined)
Transdermal Contraceptive Patch (Ortho Evra)
Vaginal Contraceptive Ring (NuvaRing)
Mini-pills (Progestin-only pills; POPs)
Emergency contraceptives
Barrier contraceptives
Diaphragm
Vaginal contraceptive sponge
Cervical cap (Prentif Cavity-rim)
Female condom (Reality)
Vaginal spermicides
Male condoms
Injectable Contraceptives
Depo-Provera
Lunelle
Intrauterine Devices
Progestasert IUD (with progesterone)
ParaGard (Copper T380A IUD)
Mirena (IUD with levonorgestrel),
Implants
Implanon
Norplant (no longer available in the US)
Sterilization
Female
Male (vasectomy)
Coitus interruptus

Unfortunately, the difference in contraceptive

effectiveness between perfect use and typical use
leads to millions of unintended pregnancies each year.
Perfect use is defined as correct, consistent, and
continued use of a method chosen by the sexually

active patient. The less patient-dependent a method,

the closer the typical usage is to the perfect usage.
Thus, methods such as the implant, DMPA, and IUDs
have typical usage that is virtually equal to perfect
usage, and the intravaginal ring and transdermal patch
have better typical usage than OCPs.

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Contraception
Table 3. Effectiveness of Methods

Method
OCP
Ortho Evra
NuvaRing
DMPA
Mirena
ParaGard
Condoms
Implanon

Perfect Use
>99%
>99%
98-99%
99.7%
99.9%
99.4%
97%
>99%

Typical Use
95%
98-99%
98-99%
99.7%
99.9%
99.2%
86%
100%*

*post marketing Pearl index of 0.024

Table 4. Methods to Deliver Steroids

Pills
Patch
Injectables
Implants
Vaginal Rings
Hormone-releasing IUDs
Table 5. Advantages of Newer Contraceptive Methods

Effective
Easy for the adolescent to use
Increased number of options
Improved compliance
Low hormone doses
Continuous low levels of hormones
Reversible

The barrier methods (male condoms, diaphragms,

cervical caps, vaginal sponges, female condoms and
vaginal spermicides) are not typically recommended
as the sole contraceptive method for adolescents,
unless they are mature and motivated enough to use
them; even then, pregnancy rates are higher than with
the methods identified above as the most effective
ones.
Over the past 20 years, a number of newer
contraceptive methods have been approved in the
United States by the Washington, DC Federal Drug
Administration;
these
include
emergency
contraceptives (Preven, Plan B), Depo-Provera,
the cervical cap, Lunelle (injectable contraceptive
with
estrogen),
Mirena
(an
IUD
with
levonorgestrel), the contraceptive patch (Ortho
Evra) and an intravaginal ring(NuvaRing). Over
the past 15 years, research has developed various

ways of contraceptive steroid release (Table 4),

producing a number of potential advantages (Table 5).
After OCPs were developed in the 1960s, the
emphasis has been on having pill formulations that
have reduced estrogen and progestin dosages along
with the development of phasic and extended dosing
regimens as well as the above mentioned newer
hormone delivery methods.
This chapter reviews some of these important
methods of contraception. Figure 1 lists frequency of
contraceptive use by sexually active adolescents in the
United States.

Oral contraceptives (OCPs; COCs)

One of the main contraceptives for several
decades has been the combined oral contraceptive
(COCs), containing synthetic estrogen (usually
ethinyl estradiol [EE], occasionally mestranol) and
synthetic progesterone (Table 6) (1-7).
The mechanisms of action for the combined birth
control pill (OCPs or COCs) to prevent pregnancy
include inhibition of ovulation, cervical mucus
thickening, endometrial atrophy, and tubal transport
changes. When discussing OCPs with adolescents, it
is helpful to note the many benefits and uses of these
pills, as listed in Table 7. OCPs are usually available
as 28 day packs which contain 21 days of active pills
containing consistent steroid dosages (mono-phasic)
and placebo pills for the last 7 days to allow the
adolescent to continue with one pill a day.
Variations are being developed, such as having
only two days of placebo for each 28 day cycle and
extended cycles.

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Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

Figure 1. Contraceptive use among never-married female adolescents 15-19 years of age who had sexual intercourse in the
past 3 months, by specified method used at last intercourse and race and Hispanic origin: united States, 2002.

Multiphasic pills have also been developed which

contain steroid dosages that vary through the month
(bi- or tri-phasic). There is no evidence that
multiphasic pills provide any benefit over monophasic formulations and are often more expensive.
There is also no evidence that one OCP brand is better
than another; only that an individual adolescent may
prefer or tolerate one brand over another. Generally, a
pill with between 20 mcg and 35 mcg of EE is
selected. While efficacy appears to be the same, pills
containing 20 mcg or less of EE have been shown to
have a greater rate of irregular bleeding than higher
dose pills.
Some females benefit from extending their
menstrual cycle to reduce the number of yearly
menstrual periods. This method can used in those
having problems worsened by their menstrual periods,
such as those with epilepsy, headaches, menorrhagia,

premenstrual tension syndrome, iron deficiency

anemia, endometriosis, coagulation disorders, those
receiving anticoagulation, athletes wishing to avoid a
cycle during an important sports event, and others. 91
day packs are currently commercially available
(Seasonique, Seasonale, LoSeasonique).
Table 6. Combined Oral Contraceptive Hormones

COCs Hormones
Estrogen
Ethinyl Estradiol
Mestranol (3 brands)
Progestins
Norgestrel
Norethindrone
Norethindrone acetate
Ethynodiol acetate
Gestodene

Levonorgestrel
Norgestimate
Desogestrel
Drospirenone

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Contraception
Table 7. Missed Oral Contraceptive Pills

EE Dosage of Pill
30-35mcg

Number of pills missed

1-2 pills missed:
Take last missed pill immediately and
continue normal pill-taking scheudule.
Back-up method not needed.

20mcg or less

1 pill missed:
Take last missed pill immediately and
continue normal pill-taking scheudule.
Back-up method not needed.

3 or more pills missed*:

Take last missed pill immediately and continue
normal pill-taking scheudule. Discard other
missed pills.
Back-up method needed for 7 days.
Consider EC.
2 or more pills missed*:
Take last missed pill immediately and continue
normal pill-taking scheudule. Discard other
missed pills.
Back-up method needed for 7 days.
Consider EC.

*If missed pills occur during 3rd week, finish active pills, discard placebos, and start new pack.
Table 8. Use of Oral Contraceptives
to Manage Various Disorders

Acne vulgaris
Coagulopathies (Anticoagulation Therapy)
Decreased risk of ectopic pregnancy, ovarian
and endometrial cancer
Dysmenorrhea
Epilepsy
Endometriosis
Headaches
Hypothalamic amenorrhea due to eating disorders,
exercise, stress
Iron Deficiency Anemia
Menorrhagia
Polycystic Ovary Syndrome (PCOS)
Premature ovarian failure/Turner syndrome
Premenstrual Syndrome (PMS)/Premenstrual Tension
Syndrome (PTS)
Rheumatoid Arthritis

OCPs may be initiated according to three different

schedules: Quick Start, First Day Start and Sunday
Start. A urine pregnancy test may be performed if
patient has had unprotected sex since last menses, and
should be repeated if next menses is missed or there
are other concerns for pregnancy. Emergency
contraception may be considered if unprotected sex
has occurred in the last 5 days.
For the Quick Start method, the patient should
take the first pill immediately and back-up
contraception should be used for 7 days (24). Quick
Start may improve compliance, decrease confusion,
and provide near immediate contraception. OCPs can

also be started on the first day of the next menses and

no back-up method is needed. Lastly, they may be
started on the Sunday after the next menses, although
back-up contraception is needed for 7 days with a
Sunday Start.
This may cause confusion, difficulty with
weekend refills, and delay in initiation, especially in
women with irregular menses. Table 8 provides
instruction on management of missed pills. The
sexually active adolescent should be instructed that
OCPs (COCs) do not prevent sexually transmitted
diseases, and thus, condoms, are also recommended.

Contraindications to OCPs/COCs
Counseling sexually active youth about OCPs
involves discussing conditions that may present
increased risks for the adolescent. The World Health
Organization (WHO) has published guidelines for
medical eligibility to help in this endeavor (Table 9).
Females in WHO Category I have no restrictions
to using OCPs, while those in WHO Category 2 have
some increased medical risk. However, OCPs and
other combined hormonal contraceptives should still
be considered for those in Category 2 as the risk of
pregnancy may outweigh the medical concerns.
Females in WHO Category 3 have such an
increased risk that they are not placed on OCPs unless
there is no other available, effective, contraceptive
agent. Finally, those in WHO Category 4 are not
placed on the OCP because the medical risks are too
great.

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Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

Table 9. WHO Medical Eligibility Categories for OCPs*

Category One (No Restrictions)

Antibiotics
Benign breast disease
Benign ovarian tumors
Cervical ectropion
Dysmenorrhea,
Endometriosis
Epilepsy
Family history of breast cancer
Gestational trophoblastic disease (benign or malignant)
Headaches (mild)
History of ectopic pregnancy or abortion (post abortion after first or second
trimester),
History of gestational diabetes
Increased STD risk
Iron deficiency anemia
Irregular menstrual bleeding
Obesity
Ovarian or endometrial cancer
Past pelvic surgery
Pelvic inflammatory disease
Postpartum at or over 21 days
Thyroid disorders (as hypo/hyperthyroidism, simple goiter)
Varicose veins
Various infections :malaria, tuberculosis, others)
Sexually transmitted diseases
Viral hepatitis carrier
Category Two (Caution)
Cervical cancer
Diabetes mellitus (uncomplicated)
Headaches (severe and if they start after beginning OCPs)
Hypertension at 140-159/100-109 mm Hg
Major surgery without prolonged immobilization
Migraine headaches without focal neurologic involvement.
Patients who have a hard time taking the OCP correctly:
drug or alcohol abuse
mental retardation
persistent history as poor OCP takers
severe psychiatric disorders
Sickle cell disease or sickle C disease
Undiagnosed breast mass
Category Three (Usually no OCP given)
Gallbladder disease
Lactating (6 weeks to 6 months),
Less than 21 days postpartum
Medications that interfere with OCP efficacy
Undiagnosed abnormal vaginal/uterine bleeding.
Category Four (OCP contraindicated)
Breast cancer
Cerebrovascular accident (active or history)
Complicated structural heart disease (with pulmonary hypertension, atrial

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Contraception
fibrillation or history of sub acute bacterial endocarditis)
Coronary (or ischemic) heart disease (active or history)
Deep vein thrombosis or pulmonary embolism (active of history)
Diabetes mellitus (complicated with retinopathy, neuropathy, nephropathy)
Headaches (including migraine headaches) with focal neurologic symptoms
Hypertension (severe: (160+/110+ mm Hg or with vascular complications)
Lactation under 6 weeks
Liver disease (including liver cancer, benign hepatic adenoma, active viral
hepatitis, severe cirrhosis)
Pregnancy, complicated
Surgery (involving the lower extremities and/or prolonged immobilization

*Used with permission from Greydanus DE: Contraception. In: Course Manual for Adolescent Health. Eds: DE Greydanus,
DR Patel, H Pratt, S Bhave. Ch. 20:309-324, 2002.

Cardiovascular risks and OCPs

If the adolescent has had a venous thrombosis in the
past, OCPs are contraindicated (25-27). Venous
thrombosis (VT) risks are greater in the adolescent
and young adult female than risks for arterial
thrombosis. Morbid obesity is a well-known risk
factor for VT, though the amount of increased risk in
the otherwise healthy adolescent is not known. Most
adolescents who develop a VT do not have
identifiable risk factors. Screening questions for
adolescents seeking OCPS in regards to VT are listed
in Table 10.
Table 10. Questions about personal/family history
of thromboembolism

1.
2.
3.
4.

Have you or a close family member

(including uncles/aunts) had blood clots in legs
or lungs?
Have you or a close family member been
hospitalized for blood clots in legs/lungs?
Have you or a close family member taken
blood thinners?
Under what circumstances did the clot form?
(e.g. during air travel)

Table 11 lists risk factors for thrombosis. Death

from cardiovascular disease (arterial and venous) can
occur among 20-24 year old females at 2-6 per
million per year.
Thus, death from the OCP is a small, but known
risk, though the risk of death from pregnancy is much
greater. The OCP should be stopped if the adolescent
has a condition requiring prolonged bed rest, as with
major surgery.

Smoking should be discouraged in the adolescent

but is not a reason by itself to avoid OCPs. Blood
pressure can increase in those on OCPs and should be
monitored. If there is a personal or family history for
increased lipids, the OCP is permitted if the low
density lipoprotein range is under 160 mg/dl or the
triglycerides under 250. Other guidelines may be used
by the clinician if these guidelines are not accepted in
ones region.
Table 11. Risk Factors for Thombosis

Pregnancy
Factor V Leiden mutation
Prothrombin mutation G20210A
Hyperhomocysteinemia from mutations in
MTHFR gene
Deficiencies of Proteins: C, S, or antithrombin III
Synthetic oestrogen use
Tobacco use
Other medical risk factors: immobilization, surgery
(especially orthopaedic and pelvic), cancer, obesity,
severe illness, other thrombophilias

OCPS and miscellaneous risks

There are a number of so-called minor adverse
effects that are well-known with OCP use, such as
headaches, mood changes, nausea, and breast
tenderness. These effects are usually tolerated, and do
disappear with cessation of the pill.
Though often linked to OCPs, there is no clear
evidence that weight gain is the directly caused by
OCP/COC use. Uterine breakthrough bleeding can be
seen with OCPs and is a common cause for stopping
the OCPs. Breakthrough bleeding usually resolves

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Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

with continued use of the same OCP. Occasionally a

change to another brand is necessary. If the break
through bleeding is significant, the patient should be
evaluated for other causes.
Adolescents with well-controlled diabetes
mellitus usually do well with low dose OCPs; OCPs
are not continued if complications arise, such as
hypertension,
retinopathy,
nephropathy,
or
neuropathy. Some clinicians recommend that OCPs
be avoided in those with migraine headaches having
auras and in those with worsening headaches on the
OCP.
Some anticonvulsants lead to reduced OCP
efficacy. These include barbiturates, phenytoin,
carbamazepine, felbamate, topiramate, and vigabatrin.
A number of other medications can also interfere with
OCP efficacy, such as rifampin, griseofulvin,
ketoconazole, itraconazole, and others. Antacids and
OCPs should be separated by at least 3 hours. Those
with active liver disease should avoid OCPs.

Transdermal hormonal contraception

The use of the patch to provide contraception has
become a popular method for many adolescents and is
based on decades-long research in using transdermal
mechanisms to deliver medication. Patients should be
advised that the same adverse effects as OCPs apply,
with the possible addition of increased breast
symptoms, and local dermatitis at the patch site. The
contraceptive patch is about the size of a matchbook
and placed on the skin in various sites: upper outer
arm, buttocks, upper torso, and abdomen; it is not
placed on the breasts or skin that is irritated or cut.
The patch produces a daily release of 20 mcg EE and
150 mcg of norelgestromin, a hormone that is the
active metabolite of norgestimate. The patch is
typically started on the first menstrual day, replaced
weekly for three weeks, and then no patch is placed
on week 4 allowing menses to occur. A Quick Start,
as discussed above, may also be used for initiation.
A different site is chosen with each patch application.
Pregnancy rates are similar to the OCPs, 0.7 to
1.24 per 100 woman-years with the patch versus 2.18
for OCPs*. This rate is not affected by exposure to
water baths or saunas, strenuous exercise, or warm,
humid climates. Increased risks for pregnancy include

wearing a patch over 7 days, patch detachment, and

not placing a patch after being off for 7 days. If the
patch detaches, it should be reattached immediately. If
the patch cannot be reattached with its own adhesive,
a new patch should be placed and the patient should
place the next patch on schedule. If the patch is off for
over 24 hours or the patient is more than 2 days late in
changing it, a back-up contraceptive method should
be used for 7 days. Some concern has been raised that
pregnancy risks may be increased in females over 90
kg. COC efficacy is reduced in obese females but is
better than noted with use of barrier methods alone.
This reduced efficacy is due to increased basal
metabolic
rates, augmented adipose
tissue
sequestration, and increased hepatic metabolism of
enzymes found in obesity.

NuvaRing vaginal ring

NuvaRing is a flexible, transparent, soft vaginal ring
made of an ethylene vinyl acetate copolymer with two
steroid reservoir cores providing a daily release of 15
mg EE and 120 mcg of etonogestrel (desogestrel
metabolite). It is placed in the vagina by the
adolescent for three weeks and then removed for one
week. Quick Start is possible. If the ring is expelled, it
is simply cleaned and placed back in the vagina; if the
ring is removed for over 3 hours, a back-up method of
contraception is needed until the ring is back in the
vagina for 7 days.
It is an excellent method of contraception for
those who are comfortable with their bodies.
Adolescents are often reticent to use the ring due to
the method of insertion and removal. Insertion can be
simplified by placing the NuvaRing in an empty
tampon applicator and using the applicator to insert
the ring. The user needs to be counseled that the ring
does not prevent STDs.
Advantages of the ring include excellent
contraceptive efficacy, easily placed as well as
removed, confidential method, continuous hormone
release, and rapid return of ovulation after cessation
of the method. Potential adverse effects include
vaginitis, vaginal discomfort, foreign body sensation,
as well as the common side effects of all COCs as
mentioned above.

Contraception

Progestin-only pills
Progestin-only pills (POPs) provide contraception by
cervical mucus thickening and endometrial atrophy;
ovulation is not reliably inhibited, leading to
pregnancy rates of 1-3 or more per 100,000.
Progestins used in POPs include 0.35 mg of
norethindrone (Micronor; Nor-Q.D) and 0.075 mg
of norgestrel (Ovrette).
POPs are suggested by some clinicians for
sexually active females with a contraindication to
estrogen (such as hypertension or coronary heart
disease). They are also used in females who are
breastfeeding. Typical adverse effects of POPs
include amenorrhea and irregular uterine bleeding.
POPs should not be used by females with ectopic
pregnancy history or taking certain medications, such
as anticonvulsants, rifampin, and griseofulvin. POPs
are not typically recommended for adolescents due to
the above increased pregnancy risk and the need for
an active pill (no placebos) to be taken at the same
time daily making compliance difficult for teens.

Emergency contraceptives
Table 12 lists some of the emergency contraceptives
(ECs) that have been available (28). The Yuzpe
regimen uses a combination of EE (100 mcg) and a
progestin and results in significant nausea due to the
high dose of estrogen (use of antiemetic is
recommended), while Plan B contains levonorgestrel
only and thus produces less nausea and has been
shown to be somewhat more effective than the Yuzpe
regimen. The expected pregnancy rate from one
unprotected coital episode is about 8%; this is reduced
to less than 1% with some ECs if used within 24
hours of unprotected sex. EC is most effective if used
within the first 72 hours after unprotected sex or

contraception failure, but may be taken up to 5 days

after coitus. If the patient is pregnant while taking
ECs, the fetus is not harmed. ECs are over-thecounter in many parts of the world. They should not
be used as regular contraception. Reasons to use ECs
include having sex without protection, slippage or
breaking of a condom, missing 2 or more oral
contraceptive pills in a row, barrier contraceptive
dislodgement (such as a diaphragm or cervical cap),
intrauterine device (IUD) dislodgement, or being over
14 weeks from the last Depo-Provera injection.

Injectable contraceptives
Medroxy-progesterone acetate (Depo-Provera;
DMPA) is a commonly used injectable contraceptive
that inhibits ovulation, thins the endometrium, and
thickens the cervical mucus. It is most commonly
used in the intramuscular formulation, but a
subcutaneous version has been developed which may
show promise for self administration in the future.
It is a reliable contraceptive if taken on a regular
basis at a dose of 150 mg every 12 weeks. A very low
pregnancy rate is noted at 0.3%. It does not contain
estrogen and thus, can be used for those with
contraindications to using estrogen. Bone loss is noted
in adolescents on this contraceptive an average of
3.1-5% after 2 years of use. However, several studies
have shown significant bone mineral density recovery
after cessation of DMPA, though it is unclear yet
whether DMPA decreases peak bone density when
used during adolescents. Therefore, DMPA should be
used with caution in youth at risk for low bone
density, such as those with chronic renal disease,
anorexia nervosa, and those with limited mobility
(29). Use of Depo-Provera often leads to irregular
menstrual periods and then, amenorrhea.

Table 12. Emergency Contraception

411

Ovral : 2 tablets by mouth immediately followed by 2 tablets in 12 hours

Lo/Ovral, Nordette or Levlen : 4 tabs and 4 more in 12 hours
TriPhasil or Tri-Levlen (yellow tabs only): 4 tabs, and 4 more in 12 hours
Ovrette: 20 tabs and 20 more in 12 hours
Preven Emergency Contraceptive Kit
Plan B: levonorgestrel, 0.75mg followed by 0.75 mg in 12 hours

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Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

Table 13. Parital List: Side-Effects of Depo-Provera

Acne
Amenorrhea
Behavioral changes (depression, anxiety, irritability)
Breast tenderness
Decreased bone density
Dizziness
Fatigue
Glucose intolerance
Hair loss
Irregular menstrual bleeding
Nausea
Weight gain

Table 13 provides a partial list of adverse effects.

Benefits of this contraceptive include reliable
contraception, reduced dysmenorrhea, less seizure
activity in some females with epilepsy, and lower
premenstrual tension syndrome.
Other injectable contraceptives that are available
are Lunelle (United States); Cyclo-Provera, and
Cyclofem (5 mg estradiol cypionate and 25 mg
medroxy-progesterone acetate [MPA/E2C]); these
combination injectables (containing estrogen and
progesterone) are given intramuscularly every month
(every 28-30 days) and have very high contraceptive
efficacy. Since it contains estrogen, dysfunctional
uterine bleeding and amenorrhea are not as common
as noted with Depo-Provera. Another injectable
product is Mesigyna (with 50 mg of norethindrone
and 5 mg of estradiol valerate).
The etonogestrel-releasing implant (available as
Implanon in the US since 2006) is a subdermal
implant consisting of one 40mm long, 2mm diameter
rod. This rod is made up of a core containing 68 mg
of etonogestrel within a rod of ethylene vinyl acetate
copolymer covered in a memberane of the same
material.
This implant is inserted subdermally, typically in
the region of the bicipital groove, using the sterile
preloaded inserter. Implanon provides 3 years of
contraception by releasing a steady dose of progestin
causing inhibition of ovulation and increasing cervical
mucus viscosity. As a progestin-only method of
contraception, the implant does not have the side
effects or contraindications associated with estrogen
containing methods. Unlike Medroxy-progesterone
acetate, the implant does not cause decreased levels of
estrogen and thus does not decrease bone density.

The benefits include high efficacy, long-acting,

non-estrogen containing, cost effective, requires little
effort of the part of the patient, rapid return to
fertility, and the benefits of other progestin only
methods.
Adverse affects include irregular bleeding,
headaches, acne, weight gain, possible mood
disturbance, and increased blood pressure. If irregular
bleeding occurs, the patient should be evaluated for
other causes.
If no other cause is found and the bleeding is
significant or disruptive for the patient, NSAIDS,
combined oral contraceptives (varying regimens), or
ethinyl estradiol have been shown to be effective to
treat break through bleeding due to the implant and
possibly other progestin-only methods as well.
The effect of Implanon may be decreased in those
with liver disease and by medications that induce
CYP3A, such as many antiepileptics, rifampin, and
St. Johns wart. Like DMPA, many women eventually
experience amenorrhea with the implant. Barriers to
use include cost and the need for insertion and
removal.
The need for removal by a trained professional
may also be seen as a benefit in the adolescent
population as this gives the practitioner an
opportunity to counsel the patient on family planning,
safer sex practices, additional contraception options,
and conduct appropriate screening prior to the
adolescent discontinuing this method, which may
decrease unintended pregnancy. Overall, implantable
contraception is an excellent option for teens.

413

Contraception

Intrauterine device (IUD)

A number of IUDs are available in the world; the
three types available in the United States are
Progestasert IUD, the ParaGard (Copper T380A)
and the Mirena IUD. Table 14 lists the
contraceptive mechanisms of IUDs. Progestasert
IUD is replaced annually and has an expulsion rate
of 2.7%, while ParaGard is replaced every 8 to 10
years and has an expulsion rate of 5%. In the United
States, concern has been raised about a possible link
between its use and pelvic inflammatory disease in
females due to often criticized research dating to the
1980s. Though controversial, it has limited the use of
IUDs in adolescents in the U.S; it is used by 12% of
contraceptive-using women throughout the world.
Data on the currently available IUDs show no
increase in risk of PID unless the patient has an
infection with Chlamydia or gonorrhea at the time of
placement. Therefore, patients should be screened for
STIs prior to IUD placement.
Table 14. IUD Contraceptive Effects

1.
2.
3.
4.
5.
6.

Prevents fertilization
Interferes with ovum development
Interferes with sperm movement and ability to
penetrate ovum
Inhibits sperm survival
Helps prevent egg release
Thickens cervical mucus

Mirena IUD (Levonorgestrel-containing IUD;

LNG-IUD) is a second-generation of steroid-releasing
IUD. It releases 20 mcg of levonorgestrel per 24
hours over the first 5 years of use, decreasing to 10
mcg per day after 5 years. It is a popular IUD used by
over 2 million women in the world. It has a failure
rate of 0.2% in the first year and 0.7% at 5 years. It
exerts a local effect on the endometrium as well as the
cervical mucus; ovulation may continue and
endometrial thinning can lead to amenorrhea. Table
15 lists potential adverse effects of Mirena IUD, the
most common of which is irregular bleeding. It has
been used to reduced menstrual bleeding in females
with dysfunctional uterine bleeding, because it can
reduced
menstrual
blood
loss
by
90%.
Contraindications to Mirena IUD use include

distorted uterine cavity, history of sub acute bacterial

endocarditis, prosthetic heart valves, and active pelvic
inflammatory disease.
Table 15. Mirena IUD Side Effects

Common
Initial increased menstrual bleeding
Abdominal pain
Uncommon
Acne/other skin problems
Back pain
Breast tenderness
Headache
Nausea
Mood changes
Rare
Hypersensitivity reaction
IUD becomes embedded in myometrium
Perforation of uterus or cervix

ParaGard (Copper T380A) is a copper T IUD

which prevents pregnancy by the interference of
sperm motility by the copper ions. ParaGard is
highly effective with a first year failure rate of 0.8%
with typical usage and a high rate of continuation
among adolescents. The primary benefit to
ParaGard is that it is non-hormonal and can
therefore be used as reliable contraception in those
with contraindications to hormone use, history of side
effects with hormonal contraception or those patients
wishing to avoid hormone usage for other reasons.
Adverse effects are primarily increased dysmenorrhea
and menstrual bleeding, abdominal pain, expulsion
and rarely perforation. Contraindications are similar
to those for Mirena. In general, IUDs are a safe,
effective, long-term method of birth control that can
be used in nulliparous adolescents. While not
recommended for teens at high risk for STIs, IUDs
have not been found to increase risk of PID, nor have
they been found to affect future fertility.

Barrier methods
Diaphragm and vaginal spermicides
Table 16 lists barrier contraceptives. These methods
are only recommended for highly motivated sexually
active individuals. Clinicians can learn to fit

414

Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

diaphragms, help determine the proper size and teach

the youth successful use of this method. The
diaphragm is used with vaginal cream or foam and is
often used with the condom. Vaginal contraceptives
or spermicides include foams, jellies, creams,
suppositories,
and
a
contraceptive
film.
Contraindications to diaphragm use are listed in Table
17 and advantages of vaginal contraceptives are listed
in Table 18. Side effects include vaginal odor and in
rare cases, allergic reactions. Females who have
diabetes mellitus and use a diaphragm have increased
risks for urinary tract infections. In rare cases, toxic
shock syndrome may occur and the diaphragm is
contraindicated in a female having a history of toxic
shock syndrome.
Table 16. Vaginal Barrier Contraceptives

Diaphragm
Cervical cap (Prentif)
Vaginal contraceptive sponge
Vaginal spermicides
Female condom (Reality)
Male condom
Table 17. Contraindications to Use of the Diaphragm

Allergy to rubber or spermicides

Anteversion (severe; forward tilting of uterus)
Complete uterine prolapse
Perineal tears
Retroversion (severe; backward tilting of uterus)
Short anterior vaginal wall
Vesicovaginal (or rectovaginal) fistulas
Toxic Shock Syndrome
Table 18. Vaginal Contraceptive Advantages

Allows the pair to share contraceptive

responsibility when used with a condom
Can reduce dyspareunia if present (vaginal
lubricant)
Cost is minimal
Prescription is not needed
Provides effective contraception, especially if
used in conjunction with condom or diaphragm
Side effects are few
Useful for young women with only occasional
coitus

Cervical cap
The Prentif cavity-rim cervical cap is a small, latex
cap (with spermicide placed inside) that is half the
size of a diaphragm and fits around the cervix via
suction. Four cervical sizes are available and about
one-fourth of females cannot be fitted with a cervical
cap. The clinician should obtain cervical cytology
before and at the time of cervical cap fitting because
cervical dysplasia has been reported in cap users;
additional cervical cytology is also recommended
three months after the fitting. Contraindications to cap
use include cervical laceration, cervical scarring, and
a history of toxic shock syndrome.

Vaginal contraceptive sponge

The sponge is made of polyurethane with a concave
shape; it is a disposable method available without
prescription, inserted in the vagina up to 2 days before
sex and left in place 6 to 24 hours after coitus.
Adverse effects include vulvar rash, vaginal odor,
pruritus, candidiasis, and increased risk for urinary
tract infection as well as toxic shock syndrome. Its
contraceptive efficacy is similar to other barrier
contraceptives.

Female condom
The female condom is a polyurethane bag or sheath
that does not require a prescription. It is placed in the
vagina prior to coitus; it is not used with a male
condom. Some STD protection is provided by the
female condom and its overall contraceptive efficacy
is similar to that of other barrier contraceptives
acceptable, but not as good as oral contraceptives.

Male condom
Male condoms are recommended to reduce the risk
for STDs as well as pregnancy. Their contraceptive
efficacy is similar to other barrier methods. They must
be used correctly with each act of coitus or their
efficacy becomes considerably reduced.

415

Contraception
Latex condoms are associated with increased
breakage rates when exposed to high temperatures
and/or ultraviolet light; they are also weakened by
exposure to oil-based lubricants. Latex allergy is
noted in 7% of the general population and the
polyurethane condom can then be used. In general,
male condom usage should be encouraged in the
adolescent population primarily for sexually
transmitted infection (STI) prevention. However,
barrier methods are typically not recommended as the
sole method of birth control in adolescents.

Conclusion
Contraception is an important concept for sexually
active youth who wish to prevent unwanted,
unplanned pregnancy. This paper has reviewed
effective methods of contraption that are available.
Clinicians caring for adolescents should ask about the
sexual behavior of these youth and provide advice on
contraception, beginning with abstinence.
Sexual responsibility involves prevention of
unwanted pregnancy, premature childbearing, and
STIs. A summary of contraceptive options for
sexually active adolescent females having chronic
illness is provided in Table 19.

Table 19. Chronic Disorders and Contraception (Greydanus, 2010; 2010; WHO, 2004; 2008; CDC, MMWR, 2010)
Disorder
AntiphosPholipid
Antibody
(aPl)
Syndrome

Recommended Methods
DMPA or the Mirena IUD/IUS

Cancer

Potentially All Methods; see various

cautions. For example:
Avoid DMPA if taking
chemotherapy due to increased risks
for infection from neutropenia or an
injection-induced hematoma due to
thrombocytopenia (TCP).
Chemotherapy-induced bone loss
may be increased by DMPA. Avoid
IUDs for those with neutropenia or
TCP. Caution with contraceptive
implants for those with TCP and
irregular menstrual bleeding.
DMPA and mini-pill are
recommended for those with CHD if
stable. Mirena IUD/IUS is usually
OK. Observe for potential adverse
reactions during IUD placement,
such as syncope, bradycardia, and
seizures. Avoid IUD if patient is on
anticoagulation due to increased risk
for bleeding with IUD placement.

Congenital
Heart
Disease
(CHD)

Concerns
See increased risks for thombosis in
these patients and thus, avoid COCs.
Avoid COCs in these patients with
moderate or high titers of
antiphospholipid antibodies (i.e., at or
over 40 GPL or MPL units).
COCs are contraindicated in those with
breast cancer. Progestin and estrogen
receptors are noted in ovarian cancer
tissue; thus, COCs are not prescribed to
patients with ovarian cancer. Avoid the
mini-pill with a positive history for
ectopic pregnancy or if taking meds
with drug interactions (i.e., certain
anticonvulsants, griseofulvin, rifampin).

Additional Comments
Risk of thrombosis is
especially increased if
other risk factors for
thrombosis are present.

Those on COCs have increased risk for

thrombophlebitis, vascular thromboses
(arterial or venous), and pulmonary
embolism. Void COCs (including patch)
with a positive history for these
conditions. See the text.
Avoid COCs if there is increased risk
for thrombo-Embolism or
endocarditisdepending on the type of
CHD. COCs (including the patch) are
avoided in those with CHD with cardiac
shunts, congestive heart disease, low
output cardiac disorders, and coronary
heart disease. Avoid COCs (including
patch) in those with CHD and
pulmonary hypertension.

Females with valvular

heart disease and other
CHD may be at
endocarditis risk during
IUD placement and one
month after the placement.
Pregnancy is associated
with increased adverse
health effects in ischemic
heart disease, complicated
valvular heart disease,
peripartum cardiomyopathy, stroke (CDC,
2010).

COCs may reduce risks

for ovarian and
endometrial carcinoma.
Pregnancy worsens breast
cancer, endometrial
cancer, ovarian cancer,
malignant gestational
trophoblastic disease,
malignant liver tumors
(hepatoma) and
hepatocellular liver
carcinoma (CDC, 2010).

416

Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

Table 19. (Continued)

Disorder
Diabetes

Recommended Methods
All methods are acceptable if
the metabolic status is stable:
COCs, DMPA, mini-pill, IUDs,
mini-pills.

Concerns
COCs should be avoided in any
adolescent female with diabetic
complications (peripheral vascular
disease, nephropathy, and retinopathy),
vascular sequelae (i.e., venous
thrombosis), or hypertension. DMPA is
safe even with the presence of diabetes
complications. IUDs may induce chronic
or resistant Candida albicans vaginiitis in
some.

Epilepsy

DMPA; IUD (Mirena and

copper); Barrier contraception

Hyperlipidemia

All methods are recommended

for stable hyperlipidemia. Use
low-dose COCs.

Hypertension

All methods are used if the

condition is stable.

Inflammatory
Bowel
Disease
(IBD)

All methods are usually

acceptable. Avoid DMPA on a
prolonged basis in those on
corticosteroids due to bone loss
exacerbation.

Caution with COCs since there can be

interference with some antiepileptic
drugs with increased pregnancy risks:
Carbamazepine (Tegretol)
Phenobarbital
Phenytoin (Dilantin)
Primidone (Mysoline)
Topiramate (mild inducer) (Topamax)
Avoid COCs if low density lipoproteins
(LDL) level is over 160 mg/dl,
triglycerides are over 250 mg/dl, or in
situations with the existence of multiple
risk factors for coronary artery disease
(CAD): diabetes mellitus, hypertension,
obesity, smoking and positive family
history for premature CAD.
Avoid estrogen-containing methods for
unstable hypertension (such as blood
pressures over 160/100 mm Hg).
Pregnancy is associated with increased
adverse health effects in uncontrolled
hypertension (CDC, 2010).
COCs may reduce bowel symptoms in
active colitis; COCs efficacy may be
lowered due to increased break-through
bleeding and reduced OC absorption. Use
the patch if gastrointestinal absorption
may be a problem. Mirena IUD/IUS
appears to be effective and safe.

Intellectual
Disability

See schizophrenia

Liver
Disease

DMPA and IUDs are safe with

active liver disease. Barrier
contraception is also fine
(except for the increased
pregnancy risks inherent in this
method).

Avoid COCs in those with active liver

disease (including hepatitis and
cirrhosis). COCs are OK when the liver
function tests return to normal. Unknown
the effect of obesity-induced NASH
(non-alcoholic steatohepatitis) on COC
efficacy.

Additional Comments
COCs do not worsen the
metabolic status. Newer OC
progestins (norgestimate,
gestodene, and desogestrel)
may cause less carbohydrate
metabolism effects than the
older progestins.
Pregnancy is associated with
increased adverse health
effects in insulin-dependant
diabetes mellitus with
complications (CDC, 2010).
Avoid Mini-pill due to
increased risk for pregnancy
and potential teratogenicity of
antiepileptic medications.
Pregnancy is associated with
increased adverse health
effects in epilepsy (CDC,
2010).
Research notes that estrogen
can lower high density
lipoprotein levels, raise LDL
levels, and increase
triglyceride levels.

COCs result in a small

increase in blood pressure
higher increase in anecdotal
situations.

DMPA may reduce breakthrough bleeding and

secondary anemia; may be
best for combination of IBD
and coagulation disorders.

Incidence of hepatic cell

adenoma is 3.4/100,000 pill
users. Pregnancy is associated
with increased adverse health
effects in severe (decompensated) cirrhosis (CDC, 2010).

417

Contraception

Migraine
Headaches

Obesity

Pulmonary
Disease

Recommended Methods
Depo-medroxyprogesterone acetate
(DMPA), the mini-pill
(progesterone-only pill),
and the Mirena IUD in
addition to barrier
contraceptives.
Levonorgestrel IUD and
mini-pills may be the best
option for the morbidly
obese adolescents. COCs or
intravaginal ring are
recommended unless
estrogen-contraindications
arise (as thromboembolism, others).
All methods are acceptable
in patients with cystic
fibrosis (CF) with no other
contraindications for
contraceptives.

Renal
Disease

If the renal disease

(including end stage renal
disease--ESRD) is stable
OK to use COCs, DMPA,
Mirena IUD/IUS, and
barrier contraception.

Rheumatoid arthritis
(RA)

COCs, Depo-Provera,
Barriers

Sickle Cell
Disorders
(SCD)

COCs, Depo-Provera,
Barriers

SLE
(Systemic
Lupus
Erythematosus)

COCs may be the best

choice.

Concerns
Females with complicated migraine
headaches (i.e., with neurological
symptoms) have heightened risk for
cerebral ischemia and cerebrovascular
accidents (CVAs) if placed on combined
oral contraceptives because of estrogen
effects
COCs are good management choices for
obese youth needing contraception as
well as polycystic ovary syndrome,
hirsutism, and acne vulgaris.
DMPA may induce weight gain and this
should be closely monitored.

Additional Comments
Use COCs with caution in those
with migraines and stop if auras
develop and/or the headaches
become worse.

COCs are safe and effective

in those with CF. Bronchial mucus is not
thickened to a major extent (as with
cervical mucus) to interfere with
contraception. Pulmonary embolism (PE)
is a rare eventavoid COCs if other high
risk factors for PE are present in CF
females.
COCs are safe for ESRD if renal state is
not impaired (stable) with no
hypertension, cardiovascular disease, and
thromboembolism. Estrogen is
contraindicated in those with ESRD with
significant hypertension or if bed-ridden.
Avoid DMPA if bone-loss is of concern.
Avoid the IUD with increased risk of
endometritis and worsening anemia.
Potential concern with IUDs due to
potential infection.
Females with severe RA may have
difficulty inserting a vaginal ring,
diaphragm, cervical cap, or other barrier
contraceptives.

Can use all methods in those with

asthma. If pulmonary tuberculosis
is present, rifampin can decrease
COC efficacy.

Pregnancy increases risk for both mother

and fetus. COCs do not increase risk due
to sickling; Depo-Provera may reduce
sickling crises. Pregnancy is associated
with increased adverse health effects in
sickle cell disease (CDC, 2010).
Avoid COCs in the presence of
vasculitis, nephritis, or APLS. Avoid the
progesterone drospirenone if renal failure
noted since hyperkalemia can develop.
Pregnancy is associated with increased
adverse health effects in SLE (CDC,
2010).

COC efficacy is reduced in obese

females but is better than use of
barrier methods alone, The
reduced efficacy is due to
increased basal metabolic rates,
augmented adipose tissue
sequestration, and increased
hepatic metabolism of enzymes.

COCs may improve menorrhagia

in some with ESRD.

Avoid COCs is there is increased

risk for vasculitis, atherosclerosis, or ischemia. See possible drug
interactions between COCs and
RA drugs, such as warfarin,
corticosteroids cyclosporine, and
some anticonvul-sants.
Sickling is a different process
than thrombosis and thus, COCs
do not increase risk for
thombosis.

DMPA may worsen bone loss

already present in SLE patients.
Avoid the IUD due to the lowered
immune status of SLE patients.

418

Donald E Greydanus, Carolyn M Lentzsch-Parcells, Hatim A Omar, et al.

Table 19. (Continued)

Disorder
Thyroid
Disease
Schizophrenia

Recommended Methods
All methods are
acceptable.
DMPA and IUDs

Miscellaneous

HIV: DMPA works

well. Alternative: IUD.

Concerns
No contraindications for contraception
with hyper/hypothyroidism.
Some females find it difficult to use
COCs or use barriers due to limited
mental health status.
HIV: Potential drug interactions between
COCs and certain anti-HIV drugs; some
cause decrease in estrogen ((lopinavir/
ritonavir and nevirapine) and some cause
an increase in estrogen (atazanavir and
efavirenz).

Acknowledgments
This paper is an adapted version of a chapter in the
book Adolescent medicine: Pharmacotherapeutics in
general, mental and sexual health edited by Donald E
Greydanus, Dilip R Patel, Cynthia Feucht, Hatim A
Omar, Joav Merrick and published with permission
by Walter de Gruyter, Berlin and New York.

Internet Sites

American College of Obstetrics and

Gynecology: http://www.acog.org
Alan Guttmacher Institute, New York:
http://www.agi-usa.org/index.html
Association
of
Reproductive
Health
Specialists: http://www.arhp.org
Cochrane Library: http://hiru.mcmaster.ca/
cochrane/cochrane/cdsr.htm
Journal
of
the
American
Medical
Association-JAMA
Contraception
Information
Center:
http://www.amaassn.org/special/contra.html
European Journal of Contraception and
Reproductive
Health:
http://www.tandf.co.uk/journals
Family Health Institute: http://www.fhi.org
Center for Disease Control, Atlanta, Georgia,
USA: http://www.health.gov/healthypeople/
World
Health
Organization
Medical
Eligibility Criteria:

http://www.who.int/reproductivehealth/publi
cations/RHR_00_2_
medical_eligibility_second_edition/index.ht
Emergency
Contraceptives
Info:
http://www.not-2-late.org

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If on levothyroxine, check T4 and
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highly controversial concept in
contemporary society.
HIV: use condoms as well to protect
partner from HIV transmission.
Pregnancy is associated with
increased adverse health effects in
HIV/AIDs (CDC, 2010).

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Submitted: October 06, 2011. Revised: November 18,

2011. Accepted: December 01, 2011.

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.